The Affordable Care Act (ACA) is expected to cover millions of newly insured Americans through Medicaid expansion and new health insurance marketplaces. During the marketplace’s first open enrollment period, which began September 1, 2013 and ended March 31, 20141, the federal Department of Health and Human Services (HHS) estimated that 8 million Americans ob-tained coverage through the marketplaces. These marketplace enrollment numbers will change as people who qualified for an extension gain coverage and are added to the rolls and those that signed up for coverage but failed to provide payment are dropped. HHS also reports that an additional 4.8 million people enrolled in Medicaid from Sept 2013 to February 2014 — about 4.2 million of these enrollees live in states that opted for the Medicaid expansion. The next open enrollment period begins on November 15, 2014.
The Congressional Budget Office (CBO) estimated that six mil-
lion Americans would enroll in private health insurance plans through the marketplaces and eight million people would enroll in Medicaid and the Children’s Health Insurance Program (CHIP) in 2014.2 By 2017, the CBO predicts that 24 million people will enroll in private health insurance plans through the marketplaces and another 12 million in Medicaid and CHIP.3 An individual mandate with penalties for not obtaining insurance and new coverage op-tions are intended to extend coverage to unprecedented numbers of Americans.
Yet, we know from prior Medicaid expansions and early expe-riences with the federal law that reaching and enrolling newly eligible individuals can be a challenge. Attracting young, healthy people, improving consumer understanding about new rules and coverage options, and bolstering enrollment when there are rela-tively small penalties for non-participation are just some of the factors that hamper efforts to enroll people in coverage. To ad-dress these challenges, the federal government and many states are adopting a wide assortment of strategies to facilitate enroll-
Medicaid and Marketplace Outreach and Enrollment Options for States
ment and minimize barriers that have hindered previous coverage efforts.
This brief discusses outreach and enrollment requirements un-der the ACA and highlights common challenges, and promising outreach and enrollment strategies and options. It is intended to help legislators identify potential roles and opportunities to en-sure that federal and state investments are helping states achieve objectives.
Things to Know About Enrollment in Your State:• What are my state’s enrollment numbers (see Figure 1 for
enrollment numbers as of April 19, 2014)?
• Enrollment in private plans vs. Medicaid?
• How do these numbers match up with projections?
• Is my state on target for enrolling young adults (ages 18-34)?
• Where are people enrolling in my state?
• What are my state’s outreach strategies?
• How are these strategies being evaluated?
• Did my state upgrade its Medicaid enrollment system?
• If so, how is it working?
OVERVIEW: OUTREACH AND ENROLLMENT REQUIREMENTS AND RESOURCES
Many Americans can benefit from information about the law’s coverage requirements and the process for obtaining coverage. The ACA does not include specific requirements for market-ing and outreach activities for health insurance marketplaces,4 and, as a result, states have a great deal of flexibility to devel-op approaches that meet their specific needs. The law requires states that opt to expand Medicaid to conduct outreach to low-income and vulnerable populations and to ensure that materials developed by the state marketplace and Medicaid agency are cul-turally and linguistically appropriate.
The federal law contains several provisions to support individu-als through the application and enrollment process. Namely, mar-ketplaces are expected to help consumers navigate the enroll-ment process by offering:• Integrated eligibility and enrollment systems. The
ACA required states to create a single, streamlined process that enables consumers to apply for, receive a determination and enroll in health coverage for which they are eligible. The law requires one single application for Medicaid and the health insurance marketplace, and an interface between the systems, so people can apply for either and enroll in the right coverage.
• Multipleavenues toapply for coverage.The ACA re-quires marketplaces to offer multiple methods and locations for completing applications, including online, by mail, over
VT
RI
DE
NHNJ
CT
DC
MA
MD
AK
WA
OR
NV
CACO
MN
HI
MT
WY
UT
AZ NM
TX
ND
SD
NE
KS
OK
IA
WI
IL
MO
AR
LA
MI
INOH
PA
NY
KY
TN
MS AL GA
FL
WV VA
NC
SC
ME
ID
AS GU MP VI PR
VT
RI
DE
NHNJ
CT
DC
MA
MD
AK
WA
OR
NV
CACO
MN
HI
MT
WY
UT
AZ NM
TX
ND
SD
NE
KS
OK
IA
WI
IL
MO
AR
LA
MI
INOH
PA
NY
KY
TN
MS AL GA
FL
WV VA
NC
SC
ME
ID
AS GU MP VI PR
VT
RI
DE
NH
NJ
CT
DC
MA
MD
AS GU MP VI PR
733,757
12,890
163,207
**68,308
76,061
36,584 10,597 48,495
11,970
125,40284,601
120,071 32,06269,221
29,30957,013 152,335
29,163
217,492
8,592
43,446
19,856
272,539
139,815
132,423154,668
318,077
44,258
216,356
357,584151,352
82,747
118,324
316,54397.87061,494
101,778983,775
370,451
42,97545,390
1,405,102
13,10438,048
161,775
14,087
10,714
28,485
79,192
40,262
31,695
67,757
Figure 1. Individuals Who Selected a Plan Through the Marketplaces (October 1, 2013 – April 19, 2014)
Individual Marketplace (as of March 2014)Federally facilitatedPartnershipState-based
Source: U.S. Department of Health and Human Services**Oregon is considering moving to the federally facilitated marketplacefor the next open enrollment period which begins November 15, 2014.
the phone or in-person at a variety of locations, which may include health centers, community-based organizations, health care providers and hospitals, public programs and re-tail storefronts.
• Navigators,in-personassistersandcertifiedapplica-tioncounselors.To meet increased demand for applica-tion and enrollment assistance, the law called for navigators, in-person assisters and certified application counselors to provide hands-on help for individuals who might need more assistance than is available over a website. All federal and state marketplaces are required to hire navigators — work-ers hired and trained by states to conduct education and outreach, help consumers enroll in coverage, provide nec-essary referrals and other duties. In-person assistors and certified application counselors perform similar functions as navigators, but unlike navigators, assisters may be funded by states’ exchange establishment grants.
Federal agencies provided grants, as well as training and tech-nical assistance resources to support outreach and enrollment in marketplaces. The Department of Health and Human Services (HHS) has distributed federal exchange establishment grants to establish health insurance marketplaces and support the develop-ment of marketing and outreach campaigns. In July 2013, HHS awarded more than $150 million in grants to 1,159 health centers in all 50 states to help patients gain coverage through the health insurance marketplace, Medicaid or CHIP.
All states, even those choosing not to expand Medicaid, are eligible to receive an enhanced federal match to develop new eligibility systems (90 percent match until Dec. 2015) and to op-erate and maintain those systems (75 percent match as long as the system meets federal standards and conditions). The Medic-aid electronic eligibility systems must be able to pass accounts
between Medicaid and the marketplaces, support a single stream-lined application, conduct electronic verifications, support the new method for determining income eligibility (Modified Adjusted Gross Income or MAGI) and support new renewal processes. In addition to financial resources, the federal Centers for Medi-care and Medicaid Services (CMS) maintains a clearinghouse of official marketing and outreach resources, including materials in multiple languages, step-by-step instructions, fact sheets and other resources. States and local stakeholders can use these re-sources to educate the public about the marketplace. Also, CMS maintains training resources and guides for navigators to help consumers through various aspects of the application and enroll-ment process.
STATE VARIATION IN ACA IMPLEMENTATIONHealth insurance marketplaces operate in every state; state in-
volvement in planning and conducting outreach and enrollment varies however, based on several factors and policy decisions, including state decisions about running the health insurance mar-ketplace and expanding Medicaid.
The ACA required creation of health insurance marketplaces in states to enable consumers to compare and purchase private health plans that meet federal and state standards; allow small businesses and people with incomes between 100 percent and 400 percent of the poverty level to access subsidies; and help fa-cilitate access to public programs such as Medicaid and CHIP. The ACA allows states to establish a state-based marketplace, default to a federally run marketplace, or, states may enter into a state-federal partnership in which each entity has responsibilities for running the marketplace. During the first open enrollment period, 16 states and the District of Columbia had state-based market-places, 27 states had federally run marketplaces and seven states
FOR YOUR CONSIDERATION: LEGISLATIVE ROLES AND OPPORTUNITIES
As described in this report, states are adopting a variety of strategies and policies to facilitate enrollment in coverage op-tions. Regardless of the political climate in the state regarding implementation of the federal law, policymakers can play an important role in outreach and enrollment, especially in mini-mizing the risks and maximizing the benefits for your state.
• Monitor and track state investments to ensure that they support cost-effective and evidence-based outreach and enrollment strategies. (See What Works on page 6 for a list of tested strategies).
• Require data collection and reporting on marketing and outreach costs and outcomes.
• Regulate navigators and assisters, for example, by considering the adequacy of training, certification and patient privacy protections
• Ensure that stakeholders are leveraging public and private outreach and enrollment resources to eliminate unnecessary
duplication of effort and cost, and ensure a coordinated approach across sectors. Assess current funding for outreach and enrollment, including navigator programs, and identify opportunities to leverage and align resources.
• Identify opportunities to streamline the enrollment process and meet consumers where they are. In addition to simplifying procedures and ensuring smooth transitions between agencies, states can consider placing navigators or assisters in non-traditional, high-need community locations.
• Foster and build relationships and strategic partnerships. As described in this brief, outreach and enrollment assistance involves partnerships with health plans, faith-based organizations, foundations and other organizations.
• Use the role of community leader to help with outreach and enrollment in their own districts.
• Extend the principle of “No wrong door,” which refers to advising and directing applicants to multiple program options including Marketplaces, Medicaid or CHIP, to additional state and local health services, such as convenient locations and other services, as allowed by ACA rules.
participated in a state-federal partnership. In 2014, “hybrids” in three states offer a federally run marketplace for the individual market and a state-run small business (or SHOP) marketplace.
The ACA expanded Medicaid coverage for low-income adults with incomes up to 133 percent of federal poverty guidelines; with an “income disregard provision,” the effective eligibility level is 138 percent. A 2012 Supreme Court decision, however, effec-tively gave states the option of expanding Medicaid or not. As of March, 2014, state actions were split, as shown in Figure 2, with 27 states and the District of Columbia opting to expand Medicaid and 23 states declining to expand Medicaid.
State decisions about marketplace oversight and Medicaid ex-pansion have several implications for outreach and enrollment. For example, states that run their own marketplace are respon-sible for consumer assistance activities, including operating a web portal, call center and navigator program, while in states that deferred to the federal marketplace, HHS is responsible for these functions. States that run their own marketplace have sig-nificantly more funding for consumer assistance through the fed-eral grants that they received to establish their marketplace than those states with federally facilitated marketplaces.
OUTREACH AND ENROLLMENT ISSUES AND CHALLENGES
As has been demonstrated at the federal level and in states that operate their own marketplace, there are myriad issues and chal-lenges that impede efforts to inform, assist and enroll individuals in health insurance marketplaces.
• Systems challenges and “handing-off” informationbetween multiple systems represents an ongoingchallengeforallstates.Although many of the initial prob-lems that thwarted enrollment in the federal online market-place in late 2013 have been addressed, work remains to ensure smooth enrollment, as well as seamless exchange of information between federal and state Medicaid programs and insurance marketplaces. With multiple agencies and da-tabases involved in determining eligibility and other func-tions, the smooth and accurate exchange of information be-tween systems is an ongoing technical challenge.
• Lowenrollmentandadverseselection — i.e., the dis-proportionate enrollment of sicker, higher-cost individuals, relative to enrollment by healthier, lower-cost individuals — have hampered prior Medicaid expansion initiatives 5 and early indications suggest that it remains a challenge with the Affordable Care Act. Drawing healthy people, including young adults, to the marketplace requires ongoing market-ing, outreach and enrollment assistance to get the word out and continually address enrollment barriers.
• Consumerconfusionisapersistentproblem.In a Feb-ruary 2014 poll, half of those surveyed said they did not understand how the law would affect them and two-thirds said they knew nothing or very little about the health insur-ance marketplaces. 6 States and the federal government are addressing this through effective education, outreach and assistance efforts.
Figure 2. State Medicaid Expansion Decisions, as of March 2014
VT
RI
DE
NHNJ
CT
DC
MA
MD
AK
WA
OR
NV
CACO
MN
HI
MT
WY
UT
AZ NM
TX
ND
SD
NE
KS
OK
IA
WI
IL
MO
AR
LA
MI
INOH
PA
NY
KY
TN
MS AL GA
FL
WV VA
NC
SC
ME
ID
AS GU MP VI PR
VT
RI
DE
NHNJ
CT
DC
MA
MD
AK
WA
OR
NV
CACO
MN
HI
MT
WY
UT
AZ NM
TX
ND
SD
NE
KS
OK
IA
WI
IL
MO
AR
LA
MI
INOH
PA
NY
KY
TN
MS AL GA
FL
WV VA
NC
SC
ME
ID
AS GU MP VI PR
VT
RI
DE
NH
NJ
CT
DC
MA
MD
AS GU MP VI PR
733,757
12,890
163,207
**68,308
76,061
36,584 10,597 48,495
11,970
125,40284,601
120,071 32,06269,221
29,30957,013 152,335
29,163
217,492
8,592
43,446
19,856
272,539
139,815
132,423154,668
318,077
44,258
216,356
357,584151,352
82,747
118,324
316,54397.87061,494
101,778983,775
370,451
42,97545,390
1,405,102
13,10438,048
161,775
14,087
10,714
28,485
79,192
40,262
31,695
67,757
Source: U.S. Department of Health and Human Services
Not expandedImplementing or exploring expansion alternativesExpanded
• Reachingdiversepopulations.A wide range of individu-als who are more likely to be uninsured can obtain coverage through marketplaces, including low-income adults, working families, young adults, and ethnic and culturally diverse pop-ulations. Developing communication and health care work-force strategies to meet the language and other needs of this diverse population is a challenge.
• Workforcepolicyissues.States also are examining policy ramifications stemming from the regulation and oversight of navigators and assisters. For example, through their work with consumers, navigators have access to Social Security numbers and other sensitive information, and some states have expressed concerns about the potential for misuse. 7
Special challenges in states not expanding Medicaid.These states, although not expanding to all Americans with ef-fective incomes up to 138 percent of the federal poverty level, will still see their Medicaid enrollment grow due to the federal marketplaces’ outreach and enrollment campaign and personal incentives to obtain coverage. This increased enrollment will place greater strain on state Medicaid budgets, because the state does not receive an enhanced federal match for those who were already eligible but not enrolled. States not expanding Medicaid are also still required to ensure a seamless partnership with the marketplace. Moreover, these states may experience additional challenges related to a coverage gap for adults with incomes un-der the poverty level (described below).
ADDRESSING CHALLENGES: STATE OUTREACH AND ENROLLMENT ACTIONS
States are not starting from scratch with their outreach and en-rollment plans. Rather, states are drawing from the lessons learned from Medicaid and CHIP expansions that preceded the ACA, as these experiences offer important lessons and best practices that can inform current state outreach and enrollment strategies.
State outreach and enrollment activities vary considerably de-
pending on a number of factors, including marketplace oversight, the state’s decision regarding Medicaid expansion, political sup-port and buy-in, and other factors. As described below, states are applying these lessons in their current outreach and enrollment work. Designoutreachcampaignsthatcombinebroadpublic
awarenesscampaignswithcommunity-based,grassrootsefforts.States that manage their own marketplace typically in-clude a mix of broad-based informational and communication strategies to inform the public, as well as targeted messages and resources to reach specific population groups. While there is great variation within states — even among states that chose the same oversight structure — states that operate their own marketplaces have tended to develop more state-specific outreach materials and messages, while states that defer to the federal government tend to have more general outreach strategies. State-run market-places use a variety of tools, such as social media, partnerships with community groups, in-person outreach (through door-to-door campaigns) and retail locations, as well as websites to sup-port campaigns and facilitate enrollment. For example, consum-ers can learn about and enroll in coverage in multiple settings in Connecticut. In addition to a call center that offers help in mul-tiple languages, and a navigator/assister program, Access Health CT provides storefront enrollment centers in two of the highest-need cities in the state; it plans to open four additional storefronts in other locations. In the final months of the open enrollment period, these storefront locations were enrolling between 300 and 400 people per day according to Access Health CT. In NewYork, the State Department of Health hired a firm to develop a cam-paign with television, print, online and transit advertising.
In states with federally run marketplaces, health plans, non-profits and other community and faith-based organizations often play a significant role in outreach and enrollment efforts.
• Recognizing the important role that faith and community leaders play in educating others about health coverage options, HHS maintains an online toolkit with links to fact
What WorksResearchers have studied Medicaid and CHIP expansions and iden-
tified several lessons that inform current outreach and enrollment initiatives.
• Marketing and public education—delivered through materials in multiple languages—raises awareness of new coverage options.
• A combination of community-based or grassroots outreach and broad marketing campaigns have proven effective at educating families about coverage, but targeted messages are needed to reach and enroll hard-to-reach individuals.
• Trusted community groups (e.g., nonprofit agencies, faith-based organizations, WIC programs, schools) connect with individuals who are traditionally hard-to-reach. Given the trusted role that most doctors have with their patients, local health care providers and community health centers are effective partners.
• In-person, one-on-one application assistance can have a significant impact on enrollment. One study in Boston found that more children received coverage if assisted by a counselor; they obtained coverage faster, and were more likely to have continuous coverage and satisfaction with the enrollment process than individuals who did not work with a counselor.
• Simplifying enrollment policies and procedures facilitates enrollment; coordinating program rules between Medicaid and CHIP and offering multiple enrollment methods contribute to increases in enrollment among Medicaid-eligible groups.
Contributing sources: “Reaching and Enrolling the Uninsured: Early Efforts to Implement the Affordable Care Act,” Robert Wood Johnson Foundation and Urban Institute (October 2013); and “Key Lessons from Medicaid and CHIP for Outreach and Enrollment Under the Affordable Care Act,” The Kaiser Commis-sion on Medicaid and the Uninsured (June 2013)
In states that have not expand-ed Medicaid to adults with incomes effectively below 138 percent of the poverty level, there will be a “coverage gap” for certain low-income people, including young adults and childless adults. Indi-viduals with incomes between 100 percent and 400 percent of the poverty level will be eligible for tax credits through the marketplaces. However, individuals with incomes below 100 percent of the poverty level may not be eligible for any coverage assistance if they live in a state that did not expand Medic-aid. In effect, they earn too much to qualify for Medicaid under their state’s rules, but they do not earn enough to qualify for help buy-ing coverage in the marketplace. This is because the ACA provides for subsidies only to people with incomes above the poverty level, and provided that others would be covered by the Medicaid expan-sion, which then was affected by the Supreme Court’s ruling that made the Medicaid expansion optional for states.
Fede
ral P
over
ty L
evel
(FPL
)
States that have not expanded Medicaidto adults with incomes
at least 100% FPL
States that have expanded Medicaidto adults with incomes
at least 100% FPL
Possible Coverage Gaps in 2014
Marketplace Subsidies*
400% FPL $46,680 for an individual
ACA Expansion 138 % FPL, $16,105 for an individual
Medicaid
Median (47%) Medicaid Eligibility for Parents.There is wide variation among states with regard to adult coverage.
Marketplace Subsidies*
100% FPL $11,670 for an individual
Medicaid
Coverage Gaps
In some areas people without coverage can still access care via community health centers, free clinics, or health providers. States often support these efforts through direct funding or supportive regulation.
SOURCE: KAISER FAMILY FOUNDATION
*Marketplace subsidi\es are available only to people with incomes between 100% and 400% FPL.
sheets, talking points and other resources.
• Blue Cross Blue Shield of NorthCarolinasponsors two mo-bile units that travel around the state, as well as seven retail stores to promote awareness and enroll consumers in health insurance. 9
• Blue Cross Blue Shield of Texaseducates consumers about the federal marketplace through a website, texting campaign and partnerships with churches, clinics, non-profit and other community organizations. 10
Engagepartnersearlyandcontinuallytofacilitateout-reachandenrollment.Active involvement of a wide array of partners is an effective strategy for disseminating information and linking people to coverage. Most states running their own marketplaces created workgroups of diverse stakeholders — state officials, insurers, health plans, health care providers, community health centers, consumer advocates and others — to plan and conduct outreach and public education. For example, Coloradoconducted numerous public meetings with individuals and orga-
nizations across the state to build partnerships and obtain stake-holder buy-in.
Faith-based organizations play an important role in connecting communities of faith to information about health coverage. For example, the MarylandCitizen’s Health Initiative created a Faith Ambassadors’ Program to train ambassadors to provide health in-surance education in multiple languages. In Alabama, the Arise Citizens’ Policy Project partners with congregations, gospel radio stations and others to inform the uninsured about coverage op-tions. 11
Remove enrollment barriers and meet consumerswheretheyare.States have established web portals, call cen-ters, and developed navigator programs to help individuals enroll. Every state has a website to promote awareness and facilitate enrollment. These websites typically provide subsidy calculators, educational videos, and resources to ease the enrollment process. To meet the varying levels of assistance needed by consumers, states have created a tiered approach that involves websites with real-time “chat” options, call centers and hands-on assistance. In January 2013, 35 states had stationed assisters in hospitals, fed-erally qualified health centers, public health offices or schools. 12
• Connect for Health Coloradohelps consumers compare op-tions through a website designed to resemble popular travel websites.
• In Mississippi, workers assigned to reservations helped in-crease enrollment among American Indians. 13
• In Utah, enrollment specialists in clinics assist families through each step of the application and enrollment process. An evaluation found that 74 percent of children in families that were provided application assistance were successfully enrolled compared to 26 percent of children at a comparison clinic in which families were provided an application but no direct enrollment assistance.
Developtrainingprogramsandrequirementsfornavi-gators.Navigators (and counselors and assisters who perform similar duties) help consumers complete applications, compare options and select coverage. These functions are not only com-plex, but they also involve handling sensitive, personal informa-tion. In response, states have considered a wide range of legisla-tion aimed at regulating and licensing navigators, defining the scope of their activities, and establishing training requirements.
In recent years, 16 states enacted laws to certify, license or regulate navigators or navigator programs.14 Other states created regulations to do the same.
Examples of navigator legislation include the following.
• Licensure.Six states require navigators to be licensed in the state. For example, Arkansasenacted SB 1189 in 2012 that requires applicants to pass an exam with standards set by the insurance commissioner, pass a criminal and regula-tory background check, and pay an annual fee in order to qualify for licensure in the state.
• Training.States vary in their training requirements for as-sisters, including length and format of training, as well as requirements for re-certification and continuing education. 15 Montana requires navigator and insurance broker and agent certification for health insurance sold in the market-
place, and legislation defines training requirements for work-ers who help people sign up for coverage through the mar-ketplace.
• Scopeofpractice.Some laws address or restrict the type of information that navigators can provide to clients. For ex-ample, four states — Georgia,Missouri,Ohioand Ten-nessee— have enacted laws restricting navigators from giving advice about the benefits, terms and features of a particular health plan. It’s worth noting that courts found two of these laws, in Missouri and Tennessee, to be pre-empted by federal regulation.
• Other requirements and limits. Some state legislation addresses the ability of navigators to sell insurance. Maineallows only licensed insurance producers to sell, solicit or ne-gotiate health insurance or enroll an individual or employer in coverage through the marketplace. Similarly, NewYorkdefines navigators as individuals who, among other things, do not sell insurance.
In addition to enacting legislation, some state marketplaces have engaged insurance agents and brokers in the develop-ment of marketplace policies. Marylandhas a Producer Advisory Council to provide input. 18
Streamlineenrollmentprocedures,includingfast-trackenrollment.Some states have adopted “fast-track enrollment” for individuals whom they know to be Medicaid-eligible through their participation in other public programs. States can apply to the Centers for Medicare and Medicaid Services (CMS) for a fast-track waiver through December 2015. 19 CMS enabled states to identify Medicaid-eligible individuals by using data that states al-ready have through the Supplemental Nutrition Assistance Pro-gram (SNAP) and Medicaid databases.20 Using this data, states can reach out to people who are likely to qualify for Medicaid and encourage them to enroll in health coverage. Alternatively, states can inform new applicants for other services that they may
UP CLOSE: THE CHALLENGES OF ENROLLING YOUNG ADULTS
Traditionally, young adults are uninsured at almost dou-ble the rate of older Americans.16 Several provisions of the ACA—extension of dependent coverage until age 26, Med-icaid expansion, premium tax credits and special lower cost “catastrophic” insurance policies—seek to bridge the gap for millions of young adults. One of the goals of outreach is to promote awareness and reduce confusion among this group. According to a March 2013 Commonwealth Fund survey of young adults, only 19 percent of people between the ages of 19 and 29 who were uninsured within the past year were familiar with the marketplaces or the expansion of Medicaid eligibility. Reaching them requires targeted outreach efforts. Because more than half of low-income young adults are already involved in other public programs, targeting outreach through these programs could reach half of uninsured young adults. 17
also be eligible for enrollment in Medicaid. As discussed earlier, using data from programs such as SNAP, Medicaid and unemploy-ment insurance compensation, states could reach more than half the Medicaid-eligible, uninsured young adults.21 While targeted enrollment strategies such as fast-track enrollment offer an ef-fective way to identify newly eligible individuals, they also raise concerns about the use of sensitive and confidential financial and household information.
• SouthCarolinauses eligibility information from other pro-grams (e.g., SNAP and Temporary Assistance for Needy Families) to expedite renewals of Medicaid. The move re-sulted in an estimated savings of $1 million in direct admin-istrative costs and 50,000 staff hours.
• Other states that have adopted fast-track eligibility include Arkansas,Illinois,Oregonand WestVirginia. 22
CONCLUSIONStates are engaged in a continuum of outreach and enrollment
strategies, some taking primary responsibility for those functions, while others rely at least in part on federal agencies to perform those activities. Despite the variation among states, opportunities exist for interested policymakers to engage with the outreach and enrollment activities to ensure that the process meets the state’s needs and supports its coverage goals.
Endnotes1 Open enrollment ended on March 31, 2014 for individuals; special
enrollment continued through April 19, 2014. Small businesses may continue to enroll through 2014. There is no deadline for enrolling in Medicaid.
2 Congressional Budget Office, Updated Estimates of the Insurance Coverage Provisions of the Affordable Care Act, Appendix B in Budget and Economic Outlook 2014-2024 (Washington, D.C., February 2014).
3 Ibid.
4 Ian Hill, Brigette Courtot and Margaret Wilkinson, Reaching and Enrolling the Uninsured: Early Efforts to Implement the Affordable Care Act (Princeton, N.J.: Robert Wood Johnson Foundation and Urban Institute, October 2013), 4.
5 Center for Medicare and Medicaid Services, Department of Health and Human Services, “Medicaid and CHIP FAQs: Enhanced Funding for Eligibility and Enrollment Systems (90/10),”originally released November 2012, accessed on March 17, 2014.
6 Sarah Dash, Christine Monahan and Kevin W. Lucia, “Health Policy Brief: Health Insurance Exchanges and State Decisions,” Health Af-fairs, July 18, 2013, 1.
7 Liz Hamel, Jamie Firth and Mollyann Brodie, “Kaiser Health Tracking Poll: February 2014,” Menlo Park, CA.: Henry J. Kaiser Family Foun-dation, February 2014).
8 “Health Policy Brief: Navigators and Assisters,” Health Affairs, Octo-ber 31, 2013.
9 T.R. Goldman, “Young Adults and the Affordable Care Act,” Health Affairs, December 16, 2013, 3.
10 Jay Hancock, “Blue Cross-Blue Shield Gets Big on Obamacare Ex-changes,” Kaiser Health News, June 21, 2013.
11 John Lumpkin, “Engaging Communities of Faith to Help Americans Gain Health Insurance,” RWJ Culture of Health Blog, November 13, 2013.
12 Jessica Stephens and Samantha Artiga, “Key Lessons from Med-icaid and CHIP for Outreach and Enrollment Under the Affordable Care Act,” Kaiser Commission on Medicaid and the Uninsured, June 2013, 8.
13 Ibid, 9.
14 NCSL Research, March 2014.
15 Ian Hill, Brigette Courtot and Margaret Wilkinson, Reaching and Enrolling the Uninsured: Early Efforts to Implement the Affordable Care Act (Princeton, N.J.: Robert Wood Johnson Foundation and Urban Institute, October 2013), 11.
16 Christine Postolowski and Abigail Newcomer, Helping Students
Understand Health Care Reform and Enroll in Health Insurance (Washington, D.C.: Center for Postsecondary and Economic Success, June 2013), 1.
17 Lisa Dubay, Genevieve Kenney and Elena Zaraboso, Medicaid and the Young Invincibles Under the ACA: Who Knew?” (Robert Wood Johnson and Urban Institute, November 2013).
18 Shelly Ten Napel and Daniel Eckel, Navigators and In-Person Assis-tors: State Policy and Program Design Considerations (Washington D.C.: Robert Wood Johnson Foundation, State Health Reform As-sistance Network, March 2013), 3,
19 Jocelyn Guyer and Tanya Schwartz, Operationalizing the New Fast Track Enrollment Options: A Roadmap for State Officials (State Health Reform Assistance Network, November 2013), 2.
20 Ibid.
21 Lisa Dubay, Genevieve Kenney and Elena Zaraboso, Medicaid and the Young Invincibles Under the ACA: Who Knew?” (Robert Wood Johnson and Urban Institute, November 2013).
22 Jocelyn Guyer and Tanya Schwarts, Operationalizing the New Fast Track Enrollment Options: A Roadmap for State Officials (State Health Reform Assistance Network, November 2013).
